41 LIBERTY HILL AVENUE- B-10-946 The C'ununum eal(h of tilassachusettS )
1 ° 130aid of Building Regulations and Standaf I5
vl t b1.t SsachLISCUS State Building Code. 780 CNIR. 7' edition I tijr
`p I /ii rl.1.211iulu�rn
1111VI Building Pcrmil Application To Construct. Repair. Reno%: to Or Dernoli.ah a / =url,' i
One- or Tern-Family Dwelling
This Section For Official Use Only
Building Permit Numb Date Applied: --- ---
S l u Ilat Ule: -
13uildina Cununissioncr/Inspector of Buildings Date
SECTION 1': SITE INFORMATION
1.2.As'sessors Nlap & Parcel Numbers —
Ma Number P:uecl Number
1.1 a Is this an accepted st et? yes_ nu_ P
1.3 Zoning information: 1.4 Property Dimensions:
Zunin District Proposed Use Lot Area ml fU Fromage Ilil
�
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Reyuirad Pruv idcd
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: us Sewage Disposal System:
Zone: _ Outside Flood Zone" Municipal El On site disposal system ❑
Public❑ Private❑ Check if yes❑
,{ gi � /f�S,ECCyTION 2: PROPERTY OWNERSHIP'
2.10
err I R p I lJ�C L(JCl(Ji� i
N etPrinU. n- Address for Service:
_
Sienature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'" (check all that apply)
New Construction ❑ Existine Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) 17 'Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Numberoi'Units_ Other ❑ Specify: _
Brief Description< f Pn posed ur ' ✓�� ��n ��A 1/��/�����.
yP1 f4l x �d i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
'Item (Labor:mdMateriolsl
I. Buildinv_ $ k r g 60 1. Building Permit Fee: $ Indicate how fee is deternvncd:
❑ Standard City/Town Application Fee -
3. Electrical $ ❑Total Project Costa (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $ I
4. Mechanical (HVAC) S List: j
5. Mechanical (Fire S
'Coral All Fees: S '
Su. ressinn)
_ / Check No heck Amount. (';uh :\nunun:,__
j b. rotal Project Cost: $ ( / �! ❑ Paid in Full ❑ Outstanding Balance Due:__.___-J
I
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSI_)
{ tVS 7, '��� License ;;Numhcf lispu:uuni late
1_ut('SL'I'ype tree hclnw)
Ty c Dcscri noon
\J
' L' Cnreslncied;u>iu3?.000Cu. I't.i
. R Restricted I&'_ F:umlt D\\ellnt�, .
171 Its{ -7( t I 6I L� .�1 >tasonrt Only
l(J f `"I (1� RC Residential RUuIIne, t'U\ei'IIP,
Trlcphunc • t,. R'S Windu IlliJ Siduie
• SF Residential Solid Fuel Burmnv % ,I, L I"'..il L;nuu
D Resideuual Demolnnm
5t Re ter'd home Int rovement o tractor (IIIC)
LL
li ' un an N�t(e r IIC �i'tr�t Name '7 / /Jy// Re_tsuau/un Number
...xpirati rtt Date
s; uture r V Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)J.. .
Workers Compensation Insurance affidavit must be coppletedand submitted with this application. Failure to prozide
this affidavit will result in the denial of the Issuance the building permit.
Signed Affidavit Attached'? Yes .......... No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN .
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I as Owner of the subicct property hereby
authorize i. to act on my behalf. in all matters
relative to work authorized y this building p mit appli - ion.
AA a
S nature ofow r I Date
SECTION . OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Aden[ hereby derlare
that the statements and information on the fo going application are true and accurate, to the best of my knowledge and
S�
behalf.
.. Print
Signature ul'Owner or Au iorized Agent Date 0 /
(Signed under the pains and penalties of Perjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Ptngram), will not have access to.the arbitration
program or guaranty fund undef M.G.L. c. I-F_'A. Other important information on the HIC Program-and
Construction Supervisor Licensing (CSL)can be found in 750 CMR Regulations I IO.R6 and I IO.R5. respectively.
i . W hen substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) .t including garage, finished basement/attics, decks orpt)
Gross living area iSq. Ft.) Habitable room court
Number of fireplaces Number of bedroom.
Number of bathrooms Number of hall/hmh-s -
rype of heating system Number ul'decks/ p,,rches t
Type ofcooling System laiclosed (Jpen -.-- — --
3. "Total Project Square Funta."e" may be substituted for"Total Project Cost" I
CITY OF SALEM
PUBLIC PROPRERTY
?� DEPARTMENT
\hU �x I':\1',1;!11�1.1\�\ti l ltl't l • 1.11 i'\I, \l.\".1i 111 �F l :� .i't�:
Workers' Compensation Insurance Afliidayit: Builders/Contraedfrs/Electricians/Plumbers
bpi licant Information Please Print Lee)bly
Name tBu,mess t Irgan!tauon IndniJuaLt: A L A
:1�itlress;�(,S N�r� yl M f e�"
City;State"Zip: SO 11m MP DI CI70 Phone #: ( '17SS) 7�41 - 0-H 2 )
Are you an employer"Check the appropriate box: - Type of project (required):
1.d 1 am a employer with A!� _ 4 ❑ I am a general contractor and 1 6. ❑ New construction
employees(full andtor part-time).* liabe hired the sub-contractors
_.Q 1 am a sole proprietor or partner-
listed on the attached sheet. : 7. ❑ Remodeling
ship and have'no employees rhese sub-contractors have 8. Q Demolition
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition . .
[No workers' rump. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.Q Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL f LED Plumbing repairs or additions
myself. [No workers' comp.. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees: [No workers' 13F�*therMz&
comp. insurance required.)
'Ally applicant that checks box#1 most also till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�Contrac ors that check this box most attached an additional sheet showing the name of the sub-cuntraetors and their workers'comp. policy infortnntion.
l ion an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. T /
Insurance Company `Jame: ,f ry
Policy#or Self-ins.
`Liicc. #: D /�� /M ` �� j ((� y� Expiration Date:�il 3 p
Job Site Address: 7/ / �d�LfT�� /7�/l A7l/t[-. City/State/Zip: - OI
Attach a copy of the workers' compens fon policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of hiGL c. 152 can lead to the imposition of criminal penalties of a
line op to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
ut'up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Imesti_atiuns offhe DIA fur insurance co%erage verification.
l du hereby crrtifi` t de the pau. curd peuulitev of perjury that the information provided above i.s true and correct
tii�m.nurt: Daft U /
Phone . 9 �g 71// oz/a y -
Official u.se only. Do not trrite in this area, to he completed by city or fown official
Ciry or Town: - Permit/License #___.___.-____
lssuim; Authority (circle one):
1. Board of Ifealth 2. Building Department 3. (-itytTow'n Clerk 4. Electrical Inspeefnr 5. Plumbing Inspector _
6. Other
Y'
Information and Instructions
%I.rs..ichuscus General Lenvs chapter I5' requlresall cnlplu%ers to pro%ide v,orkers' Cnnlpensadon lilr their employees.
Pni.Sn.111111)this statute. lit entflloree Is delined .Is el er% perS011 Ill file Sell lie of .Iilllihcr under any contract of hire.
c\prc"or implied,oral or %%riven."
.\n :ut/r/ul-er is delined as 'an indi%:dual,partmership, .association,corporation or other legal entity, or aiiy two or inure
,dlhe foregoing engaged in ajoint enterprise,and including the legal representatkes of a deceased eniploycr.or the
iecei%cr or trustee of an individual,partnership, association or other legal entity.employ Illg elllplo\'ces. Ilime%er the
,,l%ner of a dwelling house ha%mg not more than three apartments and v ho resides therein• or the occupant of the
dwelling house oranother who employs persons to do maintenance,construction or repair%lurk on such dwelling house
or on the grounds or building appunenant thereto shall not because of such clnpluynicni be deenied to-be-an-employer. . — —
\I(iL Ompler 152, %s25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the common%%'calth for any
applicant s%ho has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public a%ork until acceptable e%idence of compliance %v&the insurance ---- -_ -._
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub contractor(s) name(s),address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill,in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leases etc.)said person is NOT required to complete this affidavit..
The off ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
fhe l)epartnient's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Re%i;ed 5-'e-u5 Fax # 617-727-7749
www.mass.gov/dia
DISPOSAL OF DEBRIS AFFIDAVIT
in accordance with the provisions of M. G. L c. 40, Sec. 54, a condition of
Building Permit Number is that the debris resulting from this wort-shall
be disposed of in a properly licensed facility as defined.by ill. G. L c. 111, Sao.,
:d
1b0a.
x
The debris will be disposed at: Salem Transfer Staffon
owned by Nordsside Carting
. t
Signatures of PermA Applicant
Date .
Christooher Z®rzv
Name of Permit Applicant .
A &A Services Inc.
Firm Name
115 Norlh Street Saiarn. MA 01970
Address, City, State, Zip Code
INfassuchusetts- Department of Public -Safety-1
Board of -'Buildin Regulations and Standards,.:
Construction Supervisor License "
License: CS 57733
r
t Restricted to: 00
- CHRISTOPHER ZORZY �y
115 NORTH ST _
SALEM, MA 01970
Expiration:.5/2612 0 1 1
('ununissiuuer Tr#: 14751
[}/.� ✓lee TJorninxabztirv,¢ll� a�✓GCIe[lA¢l�b'.
S\— Board of Building Regulations and Standa^ds
'I HOME IMPROVEMENT CONTRACTOrt
Registration:, 101609
Expiration: 6/26/2010 Tr# 267870
Type PrWte Corporation
1
s A&A SERVICES, INC -
iIChristopher Zorzy
+I 5 North Street - C,gt,..aC7.u,,.,��:
Salem{MA 01970 - Administrator ++
Commonwealth of Massachusetts
Division of Occupational Safety
- Laura M.Marlin,Commissioner tr
Deleader-Contractor Iptlllh�ua"
CHRISTOPHER ZORZY
Eff.Date 04/14/to
Exp.Date 04/13/11 .
DC000440
Member of C OA E.S.T.
80
(IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIIII IIII IIII 80 ON-REN
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�y A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
WONE-MralfiRUZZU Telephone: (978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Buyers)Name Date of Contrail
Buyers)Street Address,City,Stale and Zip Code
( ff -eAIm.
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address:
The Buyer(s)listed above hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in accordance with
the prices and terms described on the front and the reverse of this agreement and any specification sheets(this'Agreemenrl,and Buyers)have requested that such
goods or services be installed or provided at Buyer's address listed above. A&A Services,Inc.('Contractor),hereby agrees to install or cause to be Installed the products
or services listed in this Agreement at the Buyer(s)address wntlen above. This Agreement represents a cash sale of goods and services. The Buyers)agree to pay in
cash the cost of the goods and servi es purchased as described herein,regardless of timing or ap novel of any financing Buyers)may seek Currant for their purchase„
RNi A;L Tc _ O,00 o c�us C ne .
Purchase Ric 7X-9m b9,6� Est.Starting Date:
Down Payment: �' CO Est.Completion Date: /
e ❑Cash
Amount Due on Start of Job: j Z'a'Ic� ❑C ck
real Card
Amount due on
J of Completion: ) No.
Amount Due on of Completion: Expiration Date:
Balance Due on Upon Completion:. CVC Code:
It is agreed and understood by and between the parties that this Agreement,front and back and any addendum,constitute the entire
understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement.
Buyer(s)hereby acknowledge that Buyer(s)has read the front and the reverse of this Agreement and has received a completed,signed
and dated copy of this Agreement,including the two attached Notice of Cancellation forms,on the date first written above. Buyers)also
(i)acknowledge that they were orally informed of their right to cancel this transaction;and(li)request that they be contacted via their
telephone numbers or e-mail,as listed above, In the event Contractor believes Buyer(s)would be interested in any additional quality
products or services of Contractor. DO NOT SIGN TBIS CONTRACT IF IT CONTAINS ANY BLANK SPACES.
A&A Services,I Buye s)
By
Signatur O ignat I
Print Name PrinrName
Signature
Print Name
You,the Buyer(s),may cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. See the following Notice of Cancellatlon form for an explanation of this right.
ARBITRATION:The wn4aztor and fee homeowner hereby mutually agree in aMance that in the event other pant Miss a terms ro marom this cpMrm either pant may submit such dispute to
e private arbitration Made which has been approved by the Secretary of the Executive OKc,of Consumer Art and Reguleflons and the Wher paM shall M numbed b submit to
such amain Lion as proved In M G.L.C.142A. _�)
rears feel Is: L+-� anyni tieh
NOTICE OF CANCELLATION
Oath of Transaction You may card Nis iransecllon,without any cenalty or pale of Transaction .You may cancel this trmn ton,without any p ndry or
Obsidian,within Knee,on dys from Ne above Ml If you Ameekanyprolaryladest obligatbq within three business Days from the aWvedale.If you cancel,any,propeM tral in,
any payments made by you under me Contract or Sale,and any negotiable insimmenl executed any payments made by you under Me Contract or Sale,and any negutlade Instrument executed
by you will be returned within 10 days following receipt by to Seller of your cancellation Mass, by you will be returned within 10 days lollidem,receipt by The Seller of your caareholon moue,
arW any securry imeand arising out of t a acfwn will be cancelled It you cancel you must eM any security infere9 arising out olthe bens Con wnl be ca�llad. If you cancel,you must
make meltable to the saideet yourieselenre.in wbs balty as goad wM'Non as when rem'rvM, make avallable to the Seller at your residence,In substandaky by gmf coal es whom rewired,
any goads delivered to you under this Contract or Sale:or you may,d you wish,comply with Na any goods coastal to you under Nis Co much or Sale;or you may,If you wish,comply with Me
Inssuccurs of the Seller rega am,the realm shipment of the goods at the Sellers expense and Instructions of the Boller regarding the nature shipment of the goods al the Sellers expense and
risk. If you do make the goods wvaila n.b the Seller and the Seller does not pick them up risk. If you do make the goods available to the seller and the Seller does not pick them up
will 20 days of the date M your NNIce of Cancellation,you may tetaN or dicaund of the 9mtls width 20 days of the dale W your Notice of Cancellatlon,you may retain or dispose of the goods
wiNOWaryfudherohligation.Ifyoufailtomakethewo savailablab Me Selleuorifwuagme whout any furlharobligation.Ifyoufeiltomakethego seveilableNMe Sellauorff ouagree
o naNm the goods totin Me Seller and fail N do so.then You remain liable for For al of all to return the goods to Me Seller and fat to do ad,Men you remain liable lot pefbnnance of all
onsysions under Me Contract Temool this bandidern,mall or color a slgnetl and!dated copy oblignions under Me corral memories,this banaactral mallmrdellvera signed and dated copy
of the tancxllahon notice or any oMm whom hands,or send a telegram,to
AdA Se cos, 15 of the candentron notice or any other written notice,or send a tel m,egra M A&A Services.115
NOM&Me,Salem,Massachusetts 01 W4 NOT LATER TIAN MIDNIGHrr OF North Shot.Same,Massachusetts 01970.NOT LATER THAN MIDNIGHT OF
(Date) (Date)
I HEREBY CANCEL THIS TRANSACTION. Consumer'ssigna m paw I HEREBY CANCEL THIS TRANSACTION. Consumorso,houte Date
A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
S Telephone:(978)741-0424 Fax: (978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No. CS057733
WINDOWS AND STORM PRODUCT SPECIFICATION SHEET
Buyer(s)Name Date of Contract
"04V Ana Rosh' �a din
Buyer(s)Street Address,City,State and Zip Code
zi( Libii !A;U SA1ac& AAA- 01470
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
RCS- _741-93 �
The Buyers)listed above hereby jointly and severally agree to purchase the goods anNor services listed below,in accordance with the prices and terms described on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,'of which this Specification
Sheet is a pad.
WINDOW REPLACEMENT
❑ Remove and dispose of# existing windows.f}fd46M
❑ Install # f I new SU n rl5£ O sj'e S windows: lr!' ,nyl ❑Wood
Options: Style Stall bww Grid pattern A0 6dl�
Color Interior (,tf-'�'Vlr��� Color Exterior U/j'1 f�-� Glass Type �Q Q�
6�!/V�ap exterior trim with aluminum: Style �ti�� Rf�'L'(CfLS711q Color " i - +�-�- �•^ �-t^�,�
-t+" indows will be installed according to the installation procedures In the portfolio. �_.�� ��µir-� r,4n).)-5
19' Ik aI411t�exterior edges. o,U yZ-{-S id-e, �an7c�1:11-kf-�'-`-)fill
Insulate where possible around new units. a,—pv1-L„'�`E G95zw�lyf5 ItO Oct"
❑ ulate window weight pockets if exist,and around new window units where possible. ST YI I�-fi
�- SIOdingwin� ���
uded in this proposal are set up,clean up,Hepa vacuum and cleaning wintlows inside and out.
Building permit included. `�`— �GCb��(,1�io lCnY1s
BAY I BOWS1 CASEMENT UNITS I Y FULL CONSTRUCTION WINDOW Ok+ (-?fit
❑ Create new window opening by cutting through existing home and framing in opening.
❑ Remove and dispose of existing unit(s)in its entirety.
Note:Electric and plumbing may exist in wall and will require additional costs to customer if need to be dealt with.
❑ Install window(s)into opening(s).
Note: If Bay or Bow install " -to include cable support system,new roof system(matching color as close as possible)
or tie into existing so system.
❑ "Bay ❑Bow asement Cher window(s)to include new interior style trim and new exterior style trim and head
�rrasningas needed. & y/� NS Q" Dj�
6d/Nate: Painting and staining not included. ��i�
STORM PRODUCTS a �i,t s SON �ii6' Lu'.S
�1v"eW�
❑ Remove and dispose of# existing storm window(s). a +TtT P�c` _V1JQA'(.]W,,,5+i P�ng _
❑ Install new storm windows# Manufacturer
Style Color Option / ., ,,
❑ Remove and dispose of# existing storm door(s). � 4 CP4\ 11 A VP IvC-}]b*--
Of Install new storm doors# Manufacturer 1 <
Style Color Type: ❑Aluminum ❑Solid Core
SPECIAL INSTRUCTIONS:
-1 S rwMin A-5-b-9
4 L (/
it is agreed and understood by and between the Parties that this Spedficadon Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This contract may not be changed or its
terms modified or varied in any way unless such changes are In writing and signed by both the Buyers)and the Contractor. Buyers)hereby acknowledge that Buyers)
has mad this Specification Sheet. ,/-, rc�yr
Contractor Initials:_:_ Date: Buyer's Initials: Dat,xg,` �/�